Bayshire Torrey Pines Post-acute
BAYSHIRE TORREY PINES POST-ACUTE in SAN DIEGO, CA — inspection on February 21, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Findings
1. A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked).
A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits.
On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1. 5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care.
A clinical chart review for Resident 1 was conducted, which indicated:
- The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25.
- Admission Medical Doctor (MD) ordered on 2/1/25 indicated, .Treatment: Sacralcoccyxgeal [tailbone and the triangular shaped bone to the lower spine] open wound.
Apply Barrier Cream To Area To Protect Skin For Maint [maintenance] Tx [treatment] x14 Days BID [twice daily] &PRN [as needed] every day and evening shift for (Skin Integrity Prevention) for 14 Days .
555746
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555746 B.
Wing 02/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshire Torrey Pines Post-Acute 13101 Hartfield Ave San Diego, CA 92130
Findings
1. A review of Resident 1's Admission Record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked).
A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits.
On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1. 5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care.
A clinical chart review for Resident 1 was conducted, which indicated:
- The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
555746
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555746 B.
Wing 02/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshire Torrey Pines Post-Acute 13101 Hartfield Ave San Diego, CA 92130